The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis

Prognostic value of Glasgow prognostic score in patients undergoing hemodialysis

INTRODUCTION

Usefulness of the Glasgow prognostic score (GPS), modified GPS (mGPS), and high-sensitivity mGPS (HS-mGPS) in the prognosis of patients undergoing hemodialysis remains unclear. This study aimed to investigate this.

METHODS

The GPS, mGPS, and HS-mGPS were calculated retrospectively in 339 patients undergoing hemodialysis; their association with all-cause mortality was analyzed using the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

Survival rates decreased according to the GPS (0, 1, and 2), but were similar between the mGPS and HS-mGPS. In the multivariate Cox proportional hazards model, the GPS, not the mGPS or HS-mGPS, was associated with a higher risk of all-cause mortality in patients with scores 1 (hazard ratio [HR]: 1.76, 95% confidence interval [CI]: 1.29-2.42, p = 0.0004) and 2 (HR: 2.87, 95% CI: 1.91-4.32, p < 0.0001) compared with score 0.

CONCLUSIONS

The GPS classified patients into poor prognostic risk groups more clearly than other scores.

Frequent In-Center Hemodialysis: Who Can Benefit From a Frequent Dialysis Approach?

Frequent (a.k.a daily hemodialysis) has continued to spark interest in the nephrology community as a way to possibly improve outcomes for the end-stage renal disease population. This is a patient population with a very high disease burden and mortality rate. The concept of dialysis adequacy in its current form has consolidated mainly around three times weekly dialysis, which has become the worldwide accepted standard. The current drive to encourage more home hemodialysis (which is a frequent dialysis regimen) has made the lessons from daily in-center hemodialysis more relevant. Frequent hemodialysis has been shown in both observational and randomized controlled studies to have some cardiovascular, mineral metabolism, and quality of life benefits. Some of what is learned from this body of literature is applicable today with increasing emphasis on home hemodialysis. This review will focus on the benefits and potential harms of daily hemodialysis to assist the practitioner in shared decision making with patients about the expected benefits and drawbacks of frequent in-center dialysis and what the expected goals should be for a frequent dialysis regimen.

Care of the chronic dialysis patient in the intensive care unit: a state-of-the-art review

Chronic dialysis patients account for a high proportion of intensive care unit admissions. The prevalent dialysis population is growing worldwide, accompanied by increasing medical complexity and comorbidities. Critical care physicians must be familiar with the unique clinical characteristics of this patient group. There is relatively little evidence specifically concerning the assessment and treatment of critically unwell individuals on long-term dialysis. This narrative review explores the approach to the management of chronic dialysis patients in the intensive care unit.

Impact of advanced lung cancer inflammation index on all-cause mortality among patients with heart failure: a systematic review and meta-analysis with reconstructed time-to-event data

BACKGROUND

Heart failure (HF) is associated with systemic inflammation and hypercatabolic syndrome, impacting body metabolism. The advanced lung cancer inflammation index (ALI) is a novel inflammatory and nutritional biomarker. We aimed to investigate the prognostic role of ALI in patients with HF.

METHODS

We comprehensively searched PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through October 2024. We conducted a pair-wise and prognostic systematic review and meta-analysis with a reconstructed time-to-event data meta-analysis. All analyses were performed using R V. 4.3.1. This meta-analysis was registered at PROSPERO (CRD42024535227).

RESULTS

We included five studies with 2,795 patients. In the pair-wise meta-analysis, ALI ≤ 25 was significantly associated with an increased incidence of all-cause mortality compared with ALI > 25 (risk ratio [RR] 1.73, 95% confidence interval [CI] 1.36-2.21, P < 0.01). On the adjusted prognostic meta-analysis, higher ALI was significantly associated with a reduction in the risk of all-cause mortality (hazards ratio [HR] 0.45, 95% CI 0.35-0.58-, P < 0.01). The reconstructed Kaplan Meier showed that ALI > 25 was significantly associated with a 56% reduction in the risk of all-cause mortality compared with ALI ≤ 25 (HR 0.44, 95% CI 0.38-0.50, P < 0.000001).

CONCLUSION

Among patients with HF, a low ALI was associated with a higher incidence of all-cause mortality rate than those with a high ALI. These findings suggest that ALI can be used for prognostic stratification and aid clinical decision-making in HF management.

Clinical features and prognostic factors of cardiorenal anemia syndrome in China: a retrospective single-center study

BACKGROUND

There is little research on cardiorenal anemia syndrome (CRAS) in China. This study was to describe the characteristics of patients with CRAS and to explore risk factors of all-cause death.

METHODS

A total of 81,795 patients were hospitalized from August 2012 to August 2021 in the nephrology department and cardiology department, of which 820 patients with CRAS were recruited into this study. The 820 patients were divided into three groups based on New York Heart Association (NYHA) functional class: a NYHA Class II group (n = 124), a NYHA Class III group (n = 492), and a NYHA Class IV group (n = 204). Demographics and laboratory tests were collected and risk factors of all-cause death were analyzed. The primary endpoint of the study was all-cause death.

RESULTS

820 patients were included, with a median age of 65.00 (51.00-75.00) years and 61.2% were men. The median follow-up was 27.0 (13.0-51.0) months. 416 (50.7%) patients died during follow-up. Age, smoking history, cerebral infarction, NYHA functional class, albumin, serum creatinine (SCr), left ventricular end-diastolic diameter (LVEDD), and left ventricular ejection fraction (LVEF) remained independent predictors of all-cause mortality risk in patients with CRAS (P < 0.05) after adjusting to the potential confounders.

CONCLUSIONS

In patients with CRAS, older age, smoking history, and more advanced systolic heart failure and renal failure correlated with worse clinical outcomes at follow-up.

Association Between Blood Urea Nitrogen/Albumin and the Incidence as Well as Progression of Type 2 Diabetes

BACKGROUND

An increased risk of multiple secondary diseases has been observed in individuals with diabetes, which contributes to the growing economic burden. Few studies have established the connection of blood urea nitrogen/albumin (BAR) with diabetes, and its link to subsequent diabetic complications and mortality remains unclear. We aimed to explore the association of BAR with the onset of type 2 diabetes mellitus (T2DM) and its dynamic progression.

METHODS

A total of 20,039 prediabetic participants aged 40-70, without diabetes or related events at baseline, were selected from the UK Biobank. We used a multistate regression model to assess the relationships between BAR and the trajectories of T2DM progression-from pre-T2DM to T2DM, complications, and ultimately mortality. Akaike information criterion (AIC), area under the curve (AUC), and C-statistic analyses were performed to compare the diagnostic performance of BAR with that of HbA1c for assessing T2DM progressions risk.

RESULTS

Over a mean 13-year follow-up, 5621 incident T2DM cases were identified, and among them, 1295 developed diabetes macrovascular complications, 574 developed diabetes microvascular complications, and 1264 died. BAR was significantly associated with the increased risk of T2DM (HR: 1.05, 95% CI: 1.02, 1.09), subsequent macrovascular complications (HR: 1.18, 95% CI: 1.12, 1.25), microvascular complications (HR 1.18, 95% CI: 1.08, 1.28), and further death (HR 1.18, 95% CI: 1.00, 1.39). The ability of BAR (AUC: 0.938, C-statistic: 0.739, p < 0.001) to predict diabetes progression was inferior to that of hemoglobin A1c (HbA1c) (AUC: 0.949, C-statistic: 0.809, p < 0.001).

CONCLUSIONS

Although BAR is significantly positively correlated with the risk of progression at different stages of diabetes, its predictive performance is inferior to that of HbA1c and comparable to that of BUN and albumin. BAR does not demonstrate sufficient clinical significance in predicting diabetes progression, highlighting the need for further investigation.

Hyperkalemia burden and treatment patterns in Chinese patients on hemodialysis: final analysis of a prospective multicenter cohort study (PRECEDE-K)

OBJECTIVES

Patients with end-stage renal disease (ESRD) on hemodialysis (HD) are at risk for hyperkalemia (HK), associated with cardiac arrhythmia and sudden death. Data on the burden of HK and management techniques among HD patients in China are still scarce. This study assessed the treatment modalities, recurrence, and prevalence of HK in Chinese HD patients.

METHODS

In this prospective cohort study conducted from May 2021 to July 2022, patients aged ≥18 years who had ESRD and were on HD were enrolled from 15 centers in China (up to 6 months).

RESULTS

Overall, 600 patients were enrolled. At the baseline visit, mean (± standard deviation) urea reduction ratio was 68.0% ± 9.70 and Kt/V was 1.45 ± 0.496. Over 6 months, 453 (75.5%) patients experienced HK, of whom 356 (78.6%) recurred. Within 1, 2, 3, 4, 5, and 6 months, 203 (44.8%), 262 (57.8%), 300 (66.2%), 326 (72.0%), 347 (76.6%), and 356 (78.6%) patients had at least one HK recurrence event, respectively. The proportions of patients with ≥1, 2, 3, 4, 5, or 6 HK recurrence events were 356 (78.6%), 306 (67.5%), 250 (55.2%), 208 (45.9%), 161 (35.5%), and 110 (24.3%), respectively. Among the 453 patients who experienced HK, only 24 (5.3%) were treated with potassium binders: seven (1.5%) with sodium polystyrene sulfonate, 13 (2.9%) with calcium polystyrene sulfonate, and six (1.3%) with sodium zirconium cyclosilicate.

CONCLUSION

Since HK is a chronic illness, long-term care is necessary. Patients on HD should have effective potassium management on non-dialysis days, yet our real-world population rarely used potassium binders.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04799067.

Association of Frailty with Postoperative Survival and Outcomes Following Hemodialysis Vascular Access Creation

BACKGROUND

The literature suggests that for patients to experience the purported advantages of an arteriovenous fistula (AVF) over arteriovenous graft (AVG), a minimum survival of 18 months is required. With the vascular access guideline shift away from "Fistula First" toward shared decision making, patient survival after vascular access creation is a major factor to consider in optimal access selection. The objective of this study is to examine outcomes of vascular access in patients with short survival and factors associated with short survival, including frailty.

METHODS

We performed a retrospective review of 200 access procedures performed between August 2018 and November 2020 at a single institution. Maturation was defined as the date when the surgeon deemed the access ready to be used for dialysis. A modified Risk Analysis Index (RAI) score was used to calculate frailty.

RESULTS

Within 3 years after access creation, 55 (27.5%) patients were recorded as dead (mortality within 3 years of access creation [3YMORT]). In the 3YMORT group, 5 did not follow-up with the surgeon prior to death and 22/34 (65%) of AVF versus 15/16 (94%) of AVGs were deemed mature prior to death (P = 0.03). Of the accesses that matured, the median days to maturation for AVF was 69 (interquartile range [IQR] 53, 87) versus 28 (IQR 18, 32) for AVG (P < 0.001). Patients in the 3YMORT group were older (70.6 vs. 63.4, P = 0.004) and had a lower body mass index (24.8 vs. 27.4, P = 0.03). Patients in the 3YMORT group had higher prevalence of dysrhythmia (35% vs. 15%, P = 0.002), chronic obstructive pulmonary disorder (20% vs. 10%, P = 0.048) and dialysis dependence at the time of access creation (91% vs. 75%, P = 0.01). There was no significant difference in sex, white race, Hispanic ethnicity, coronary artery disease, congestive heart failure, previous coronary artery bypass graft or percutaneous coronary intervention, diabetes, hypertension, and peripheral arterial disease between the 2 groups. The 3YMORT group had a significantly higher prevalence of frailty (78% vs. 49%, P = 0.0002). Patients categorized as frail by the RAI had a significantly higher risk of 3YMORT (odds ratio [OR] 3.74, 95% confidence interval [CI] 1.82-7.66) compared to nonfrail patients. Patients categorized as very frail by the RAI had an even higher risk of 3YMORT (OR 4.20, 95% CI 1.95-9.05), compared to nonfrail patients.

CONCLUSIONS

Patients with short life expectancy after vascular access creation may have high rates of AVF nonmaturation and longer time to maturation. Factors associated with high risk of mortality within 3 years of vascular access creation correlate well with factors included in the RAI frailty score. Patients who are frail or very frail may be appropriate candidates for AVG creation over AVF considering their high risk for short life expectancy.

IL-6 inhibition with clazakizumab in patients receiving maintenance dialysis: a randomized phase 2b trial

Inflammation mediated by interleukin-6 (IL-6) is strongly associated with cardiovascular risk. Here we evaluated clazakizumab, a monoclonal antibody targeting the IL-6 ligand, in a phase 2b dose-finding study. Adults with cardiovascular disease and/or diabetes receiving maintenance dialysis with high-sensitivity C-reactive protein (hs-CRP) ≥ 2 mg l-1 at baseline were randomized to receive clazakizumab (2.5 mg, 5 mg or 10 mg, n = 32 per dose group) or placebo (n = 31) every 4 weeks. The primary endpoint was the change from baseline in hs-CRP to week 12, expressed as the geometric mean ratio. Clazakizumab treatment signficantly reduced serum hs-CRP concentrations at week 12 by 86%, 90% and 92% relative to placebo in patients randomized to 2.5 mg, 5 mg or 10 mg clazakizumab, respectively (all P < 0.0001), meeting the primary outcome. With regard to secondary endpoints, clazakizumab treatment reduced serum fibrinogen, amyloid A, secretory phospholipase A2, and lipoprotein(a) concentrations, as well as increased mean serum albumin concentrations at 12 weeks, relative to placebo. The proportion of patients who achieved hs-CRP < 2.0 mg l-1 was 79%, 82% and 79% in the 2.5 mg, 5 mg and 10 mg clazakizumab groups, respectively, compared with 0% of placebo-treated patients. With regard to safety, no cases of sustained grade 3 or 4 thrombocytopenia or neutropenia were observed. Serious infections were seen with similar frequency in the placebo, clazakizumab 2.5 mg and clazakizumab 5 mg groups, but were numerically more frequent in the clazakizumab 10 mg group. The results of this trial indicate that in patients receiving maintenance dialysis, clazakizumab reduced inflammatory biomarkers associated with cardiovascular events. ClinicalTrials.gov registration: NCT05485961 .

Adequacy of Dialysis and Incidence of Atrial Fibrillation in Patients Undergoing Hemodialysis

BACKGROUND

Atrial fibrillation (AF) can lead to stroke, heart failure, and mortality and has a greater prevalence in dialysis patients than in the general population. Several studies have suggested that uremic toxins may contribute to the development of AF. However, the association between dialysis adequacy and incident AF has not been well established.

METHODS

In this retrospective nationwide cohort study, we analyzed data from the Korean National Periodic Hemodialysis Quality Assessment from 2013 to 2015 of patients who received outpatient maintenance hemodialysis 3× a week. The main exposure was single pooled Kt/V (spKt/V), which is the dialysis adequacy index, and the primary outcome was the development of AF. For the primary analysis, patients were categorized into quartiles according to baseline spKt/V. The lowest quartile, representing the lowest adequacy, was used as the reference group. Fine-Gray subdistribution hazard models were used, treating all-cause mortality as a competing risk.

RESULTS

Of 25 173 patients, the mean age was 60 (51-69) years, and 14 772 (58.7%) were men. During a median follow-up of 5.7 years, incident AF occurred in a total of 3883 (15.4%) patients. Participants with a higher spKt/V tended to have lower AF incidence. In survival analysis, a graded association was observed between the risk of incident AF and spKt/V quartiles: subdistribution hazard ratios and 95% CIs for the second, third, and the highest quartile compared with the lowest quartile were 0.90 (95% CI, 0.82-0.98), 0.84 (95% CI, 0.77-0.93), and 0.79 (95% CI, 0.72-0.88), respectively.

CONCLUSIONS

This nationwide cohort study showed that a higher spKt/V is associated with a reduced risk of incident AF. These findings suggests that reducing uremic toxin burden through enhanced dialysis clearance may be associated with a lower risk of AF development in patients undergoing maintenance hemodialysis.

Beyond Numbers: How Biochemical Parameters Can Predict Outcomes in Chronic Kidney Disease Patients on Maintenance Hemodialysis

Introduction The treatment and management of patients undergoing maintenance hemodialysis (MHD) requires constant evaluation through the assessment of biochemical markers. This is necessary for treatment, to prevent progression to complications such as mineral bone disease, and to improve quality of life. We aimed to study the biochemical profile of patients with chronic kidney disease (CKD) grades 4 and 5 on MHD, identify markers altered due to different etiologies, duration of illness, and duration of hemodialysis, and create a panel of markers that can be useful in planning better management. Methods All consecutive patients attending the dialysis unit of ESIC Super Speciality Hospital with CKD grade 4 or grade 5 on MHD between 2019 and 2020 were recruited. A detailed clinical history and demographic profile were taken, and blood samples were collected from the patients during follow-up visits in plain and EDTA (ethylenediamine tetraacetic acid) tubes for analysis. Results A total of 312 patients (22.1% females and 77.9% males.) with a mean age of 49.74 ± 11.49 years were recruited. In the study population, diabetic nephropathy (DN) (17%) and hypertensive nephropathy (48.7%) were the two most prevalent causes of CKD. The majority (64%) of the patients were on MHD three times a week. The range of estimated glomerular filtration rate (eGFR) (ml/min/1.73 m2) at the time of initiation of MHD was 2.9-26.8 according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. The mean duration of MHD was 51.58 months, with a mortality rate of 5.9% during the follow-up period (3-108 months). Conclusion Optimal selection and combination of biochemical tests will help in ascertaining the adequacy of management, progress of disease, or complications in MHD patients. This in turn will help guide the clinicians in effectively using these markers in their day-to-day practice.

A Pilot Study on the Safety and Adequacy of a Novel Ecofriendly Hemodialysis Prescription-Green Nephrology

Introduction

Hemodialysis (HD) units require large quantities of water. To reduce water consumption without compromising the adequacy and safety of dialysis, we studied a novel HD prescription with high temperature and low flow dialysate.

Methods

This was a single-center nonrandomized open-label cross-over pilot trial in patients with end-stage kidney disease on maintenance HD. Each participant was subjected to 3 different dialysis prescriptions for 1 month each as follows: (i) normal temperature with normal flow dialysate (NTNF prescription), (ii) high temperature with normal flow dialysate (HTNF prescription), and (iii) high temperature with low flow dialysate (HTLF prescription). The primary outcome, assessed at the end of each dialysis session, was the delivery of "adequate" dialysis, as defined by a single-pool Kt/V (spKt/V) ≥1.2. Outcomes were evaluated by comparing the NTNF and HTLF prescriptions.

Results

A total of 863 sessions of HD were performed in 30 patients over 3 months, with 287 to 288 sessions in each of the 3 dialysis prescriptions. The primary outcome was not significantly different between the NTNF prescription (202 sessions [70.14%]) and the HTLF prescription (198 sessions [68.75%]) (odds ratio, 1.07; 95% confidence interval, 0.75 to 1.52; P = 0.45). The mean spKt/V and urea reduction ratio (URR) were not significantly different. Clinically evident hemodynamic instability occurred in only 1 dialysis session in the HTNF prescription.

Conclusion

Increasing dialysate temperature while reducing dialysate flow rate (QD) can be used as a water conservation strategy without compromising the adequacy and safety of dialysis in young and hemodynamically stable patients. Reducing the QD from 500 ml/min to 300 ml/min reduces water consumption by 40%.

Iron Metabolism and Inflammatory Mediators in Patients with Renal Dysfunction

Chronic kidney disease (CKD) affects around 850 million people worldwide, posing significant challenges in healthcare due to complications like renal anemia, end-stage kidney disease, and cardiovascular diseases. This review focuses on the intricate interplay between iron metabolism, inflammation, and renal dysfunction in CKD. Renal anemia, prevalent in CKD, arises primarily from diminished erythropoietin (EPO) production and iron dysregulation, which worsens with disease progression. Functional and absolute iron deficiencies due to impaired absorption and chronic inflammation are key factors exacerbating erythropoiesis. A notable aspect of CKD is the accumulation of uremic toxins, such as indoxyl sulfate (IS), which hinder iron metabolism and worsen anemia. These toxins directly affect renal EPO synthesis and contribute to renal hypoxia, thus playing a critical role in the pathophysiology of renal anemia. Inflammatory cytokines, especially TNF-α and IL-6, further exacerbate CKD progression and disrupt iron homeostasis, thereby influencing anemia severity. Treatment approaches have evolved to address both iron and EPO deficiencies, with emerging therapies targeting hepcidin and employing hypoxia-inducible factor (HIF) stabilizers showing potential. This review underscores the importance of integrated treatment strategies in CKD, focusing on the complex relationship between iron metabolism, inflammation, and renal dysfunction to improve patient outcomes.

Single-pool model urea clearance index is associated with sarcopenia and nutritional status in patients undergoing maintenance hemodialysis: a cross-sectional study

BACKGROUND

The single-pool model urea clearance index (single-pool Kt/Vurea; spKt/V) is the most commonly used method for dialysis adequacy assessment. However, only a few studies have examined the relationship between spKt/V values and parameters related to sarcopenia and nutritional status. This study aimed to evaluate whether the spKt/V is an indicator of sarcopenia and nutritional status in patients undergoing maintenance hemodialysis (MHD).

METHODS

A total of 142 patients were included in this single-center, cross-sectional study. Venous blood samples were collected shortly before the hemodialysis session. The adequacy of dialysis in patients receiving MHD was assessed using spKt/V. Sarcopenia was identified according to the Asian Working Group for Sarcopenia (2019) definition. Receiver operating characteristic curve and area under the curve were used to evaluate the predictive value of spKt/V in sarcopenia. Univariate and multivariate binary logistic regression analyses were used to determine the association between spKt/V and sarcopenia and nutritional status.

RESULTS

The mean spKt/V level was 1.3 ± 0.2, the prevalence of sarcopenia was 15.5% in patients on MHD. The best cutoff value of spKt/V in sarcopenia was 1.45 for both sexes, 1.33 and 1.45 for men and women, respectively (P < 0.05). The multivariate binary logistic regression shown that the spKt/V was independently positively associated with sarcopenia (OR = 122.88, 95% CI = 0.64-0.87, P = 0.002). Grouping spKt/V by the best cutoff value, when spKt/V ≥ 1.45, the OR of sarcopenia was 11.75 (95% CI = 3.16-43.67, P < 0.001). Subgroup analyses showed that when spKt/V ≥ 1.33 in men and spKt/V ≥ 1.45 in woman, the OR of sarcopenia was 9.73 (95% CI = 2.25-42.11, P = 0.002) and 14.52 (95% CI = 1.06-199.67, P = 0.045), respectively.

CONCLUSIONS

The present study showed that spKt/V was an important influencing factor of sarcopenia and malnutrition in Asian patients on MHD.

Dialysis decision-making process by Chinese American patients at an urban, academic medical center: a retrospective chart review

BACKGROUND

Clinical practice guidelines emphasize shared decision-making for kidney replacement treatment, yet little is known about the influence of cultural differences on that process. We undertook a retrospective chart review to explore the process and timing of dialysis decision making and initiation in Chinese American patients to provide quality kidney care for this population.

DESIGN

Participants received outpatient care at Tufts Medical Center and dialysis at Dialysis Clinic, Inc. Boston or Somerville, MA from 2001-2021. Clinic chart review sourced demographic, clinical, and end-of-life care information from 180 participants (82 Chinese American, 98 other) from stage 4 chronic kidney disease (CKD) and dialysis initiation.

RESULTS

Chinese American participants were older (mean 70 vs. 59, p < 0.0001), less likely to speak English (12% vs. 87%, p < 0.0001), and used interpreter services more (80% vs. 11%, p < 0.0001). Chinese American participants had more visits (median 14 vs. 10, p = 0.005); were more often accompanied by family members (75% vs. 40%, p < 0.001); and had significantly lower rates of healthcare proxy documentation (35% vs. 55%, p = 0.006). There was no statistical difference in months between first CKD 4 visit and first dialysis. Both groups started dialysis at the same average eGFR and with similar rates of permanent dialysis access. Chinese American participants had significantly lower serum albumin at dialysis initiation (mean 3.3 g/dL vs 3.7 g/dL, p = 0.0003). Documentation reflected a low number of conversations about non-dialytic care, end-of-life planning, or palliative care in both groups across all visits.

CONCLUSION

The time between CKD 4 and dialysis initiation was the same in both groups, suggesting a similar overall outcome of care. Chart documentation suggests that Chinese American participants had a significantly higher number of visits with nephrologists where discussion about dialysis was noted and were more likely to have a family member present at the visit. Fewer Chinese American participants completed healthcare proxies. Among all study participants, healthcare proxy, code status, and palliative care discussions were reported less frequently than expected. These findings highlight opportunities for collaboration between palliative care clinicians and nephrologists.

Peritoneal dialysis fluids

There have been significant advances in the understanding of peritoneal dialysis (PD) in the last 40 years, and uptake of PD as a modality of kidney replacement therapy is increasing worldwide. PD fluids, therefore, remains the lifeline for patients on this treatment. Developing these fluids to be efficacious in solute clearance and ultrafiltration, with minimal adverse consequences to peritoneal membrane health and systemic effects is a key requirement. Since the first PD fluid produced in 1959, modifications to PD fluids have been made. Nonetheless, the search for that ideal PD fluid remains elusive. Understanding the components of PD fluids is a key aspect of optimizing the successful delivery of PD, allowing for individualized PD prescription. Glucose remains an integral component of PD fluids; however, its deleterious effects continue to be the impetus for the search of an alternative osmotic agent, and icodextrin remains the main alternative. More biocompatible PD fluids have been developed and have shown benefits in preserving residual kidney function. However, high cost and reduced accessibility remain deterrents to its widespread clinical use in many countries. Large-scale clinical trials are necessary and very much awaited to improve the narrow spectrum of PD fluids available for clinical use.

Data-driven, two-stage machine learning algorithm-based prediction scheme for assessing 1-year and 3-year mortality risk in chronic hemodialysis patients

Life expectancy is likely to be substantially reduced in patients undergoing chronic hemodialysis (CHD). However, machine learning (ML) may predict the risk factors of mortality in patients with CHD by analyzing the serum laboratory data from regular dialysis routine. This study aimed to establish the mortality prediction model of CHD patients by adopting two-stage ML algorithm-based prediction scheme, combined with importance of risk factors identified by different ML methods. This is a retrospective, observational cohort study. We included 800 patients undergoing CHD between December 2006 and December 2012 in Shin-Kong Wu Ho-Su Memorial Hospital. This study analyzed laboratory data including 44 indicators. We used five ML methods, namely, logistic regression (LGR), decision tree (DT), random forest (RF), gradient boosting (GB), and eXtreme gradient boosting (XGB), to develop a two-stage ML algorithm-based prediction scheme and evaluate the important factors that predict CHD mortality. LGR served as a bench method. Regarding the validation and testing datasets from 1- and 3-year mortality prediction model, the RF had better accuracy and area-under-curve results among the five different ML methods. The stepwise RF model, which incorporates the most important factors of CHD mortality risk based on the average rank from DT, RF, GB, and XGB, exhibited superior predictive performance compared to LGR in predicting mortality among CHD patients over both 1-year and 3-year periods. We had developed a two-stage ML algorithm-based prediction scheme by implementing the stepwise RF that demonstrated satisfactory performance in predicting mortality in patients with CHD over 1- and 3-year periods. The findings of this study can offer valuable information to nephrologists, enhancing patient-centered decision-making and increasing awareness about risky laboratory data, particularly for patients with a high short-term mortality risk.

Albumin determined by bromocresol green leads to erroneous results in routine evaluation of patients with chronic kidney disease

OBJECTIVES

Measurement of plasma albumin is pivotal for clinical decision-making in patients with chronic kidney disease (CKD). Routinely used methods as bromocresol green (BCG) and bromocresol purple (BCP) can suffer from aselectivity, but the impact of aselectivity on the accuracy of plasma albumin results of CKD-patients is still unknown. Therefore, we evaluated the performance of BCG-, BCP- and JCTLM-endorsed immunological methods in patients with various stages of CKD.

METHODS

We evaluated the performance of commonly used albumin methods in patients with CKD stages G1 through G5, the latter divided in two groups based on whether they received hemodialysis treatment. In total, 163 patient plasma samples were measured at 14 laboratories, on six different BCG and BCP-platforms, and four different immunological platforms. The results were compared with an ERM-DA-470k-corrected nephelometric assay. The implications on outcome is evaluated by the proportion of patient results <38 g/L for the diagnosis of protein energy wasting.

RESULTS

Albumin results determined with BCP- and immunological methods showed the best agreement with the target value (92.7 and 86.2 %, respectively vs. 66.7 % for BCG, namely due to overestimation). The relative agreement of each method with the target value was platform-dependent, with larger variability in agreement between platforms noted for BCG and immunological methods (3.2-4.6 and 2.6-5.3 %) as opposed to BCP (0.7-1.5 %). The stage of CKD had similar effects on the variability in agreement for the three method-groups (0.6-1.8 % vs. 0.7-1.5 % vs. 0.4-1.6 %). The differences between methods cause discrepancies in clinical decision-making, as structurally fewer patients were diagnosed with protein energy wasting upon using BCG-based albumin results.

CONCLUSIONS

Our study shows that BCP is fit for the intended use to measure plasma albumin levels in CKD patients from all stages, including patients on hemodialysis. In contrast, most BCG-based platforms falsely overestimate the plasma albumin concentration.

Heparin-Immobilized Polyethersulfone for Hemocompatibility Enhancement of Dialysis Membrane: In Situ Synchrotron Imaging, Experimental, and Ex Vivo Studies

The goal of the current study is to enhance the hemocompatibility of polyethersulfone (PES) membranes using heparin immobilization. Heparin was immobilized covalently and via electrostatic interaction with the positively charged PES surface (pseudo-zwitterionic (pZW) complex) to investigate the influence of each method on the membrane hemocompatibility. In situ synchrotron radiation micro-computed tomography (SR-µCT) imaging, available at the Canadian Light Source (CLS), was used to critically assess the fibrinogen adsorption to the newly synthesized membranes qualitatively and quantitatively using an innovative synchrotron-based X-ray tomography technique. The surface roughness of the synthesized membranes was tested using atomic force microscopy (AFM) analysis. The membrane hemocompatibility was examined through the ex vivo clinical interaction of the membranes with patients' blood to investigate the released inflammatory biomarkers (C5a, IL-1α, IL-1β, IL-6, vWF, and C5b-9). The presence and quantitative analysis of a stable hydration layer were assessed with DSC analysis. Surface modification resulted in reduced surface roughness of the heparin-PES membrane. Both types of heparin immobilization on the PES membrane surface resulted in a decrease in the absolute membrane surface charge from -60 mV (unmodified PES) to -13 mV for the pZW complex and -9.16 mV for the covalently attached heparin, respectively. The loss of human serum fibrinogen (FB) was investigated using UV analysis. The PES membrane modified with the heparin pseudo-ZW complex showed increased FB retention (90.5%), while the unmodified PES membrane and the heparin covalently attached PES membrane exhibited approximately the same level of FB retention (81.3% and 79.8%, respectively). A DSC analysis revealed an improvement in the content of the hydration layer (32% of non-freezable water) for the heparin-coated membranes compared to the unmodified PES membrane (2.84%). An SR-µCT analysis showed that the method of heparin immobilization significantly affects FB adsorption distribution across the membrane thickness. A quantitative analysis using SR-µCT showed that when heparin is attached covalently, FB tends to be deposited inside the membrane pores at the top (layer index 0-40) membrane regions, although its content peak distribution shifted to the membrane surface, whereas the unmodified PES membrane holds 90% of FB in the middle (layer index 40-60) of the membrane. The ex vivo hemocompatibility study indicates an improvement in reducing the von Willebrand factor (vWF) for the heparin pseudo-ZW PES membrane compared to the covalently attached heparin and the untreated PES.

Survival in hemodialysis in Brazil according to the source of payment for the treatment: Public Healthcare System (SUS) versus private insurance

INTRODUCTION

Brazil has the largest public and universal healthcare system in the world, but little is known about the outcomes of patients on hemodialysis (HD) in the country according to the source of funding for the treatment.

OBJECTIVE

To compare the profile and survival of patients under HD treatment funded by the Public Healthcare System (SUS) to those with private insurance.

METHODS

Retrospective analysis of adults undergoing HD between 2012 and 2017 in 21 dialysis centers in Brazil that provided both by the SUS and private health insurance. Participants, regardless of the paying source, received similar dialysis treatment. Data were censored after 60 months of follow-up or at the end of 2019.

RESULTS

4,945 patients were included, 59.7% of which were financed by the SUS. Patients financed by SUS, compared to those with private insurance, were younger (58 vs. 60 years; p < 0.0001) and with a lower prevalence of diabetes (35.8% vs. 40.9%; p < 0.0001). The 60-month survival rates in these groups were 51.1% and 52.1%, respectively (p = 0.85). In the analysis of the subdistribution proportional hazard ratio by the Fine-Gray model, including adjustment for concurrent outcomes, a significant increase in the risk ratio for death was found (1.22 [95% confidence interval 1.04 to 1.43]) in patients with treatment funded by the SUS.

CONCLUSIONS

Patients on HD with treatment funded by the SUS have a higher adjusted risk of death when compared to those with private insurance, despite similar dialysis treatment. Factors not directly related to dialysis therapy could explain this difference.

Synthesis and activity study of novel N,N-diphenylurea derivatives as IDO1 inhibitors

Indoleamine 2,3-dioxygenase 1 (IDO1) has attracted much attention in the field of cancer immunotherapy as an immunomodulatory enzyme. To identify potential IDO1 inhibitors, a novel series of compounds with N,N-diphenylurea and triazole structures were synthesized. The designed compounds underwent organic synthesis, and subsequent enzymatic activity experiments targeting IDO1 confirmed their activity at the molecular level. These experiments provided validation for the efficacy of the designed compounds in inhibiting IDO1, compound 3g exhibited an IC₅₀ value of 1.73 ± 0.97 μM. Further molecular docking study further explained the binding mode and reaction potential of compound 3g with IDO1. Our research has resulted in a series of novel IDO1 inhibitors, which is beneficial to the development of drugs targeting IDO1 in numerous cancer diseases.

The prognostic value of URR equals that of Kt/V for all-cause mortality in Taiwan after 10-year follow-up

Kt/V and URR (urea reduction ratio) measurements represent dialysis adequacy. Single-pool Kt/V is theoretically a superior method and is recommended by the Kidney Disease Outcomes Quality Initiative guidelines. However, the prognostic value of URR compared with Kt/V for all-cause mortality is unknown. The effect modifiers and cut-off values of the two parameters have not been compared. We investigated 2615 incident hemodialysis patients with URR of 72% and Kt/V (Daugirdas) of 1.6. The average patient age was 59 years, 50.7% were female, and 1113 (40.2%) died within 10 years. URR and Kt/V were both positively associated with nutrition factors and female sex and negatively associated with body weight and heart failure. In Cox regression mod-els for all-cause mortality, the hazard ratios (HRs) of high URR groups (65-70%, 70-75%, and > 75%) and the URR < 65% group were 0.748 (0.623-0.898), 0.693 (0.578-0.829), and 0.640 (0.519-0.788), respectively. The HRs of high Kt/V groups (Kt/V 1.2-1.4, 1.4-1.7, and > 1.7) and the Kt/V < 1.2 group were 0.711 (0.580-0.873), 0.656 (0.540-0.799), and 0.623 (0.498-0.779), respec-tively. In subgroup analysis, Kt/V was not associated with all-cause mortality in women. The prognostic value of URR for all-cause mortality is as great as that of Kt/V. URR > 70% and Kt/V > 1.4 were associated with a higher survival rate. Kt/V may have weaker prognostic value for women.

[Unintentional weight loss in chronic kidney disease]

If the causes of unintended weight loss are already diverse in pre-dialysis patients, at the stage of dialysis requirement a variety of other causes are added. Both stages share a trend towards loss of appetite and nausea, whereby uremic toxins certainly do not represent the only cause. In addition, both stages involve increased catabolism and therefore a higher calorie requirement. In the dialysis stage, protein loss (more in peritoneal dialysis than in hemodialysis) and the sometimes extensive dietary restrictions (low potassium, low phosphate, fluid restriction) are added. The problem of malnutrition, especially in dialysis patients, has been increasingly recognized in recent years, and there is a trend towards improvement. Initially, the causes of weight loss were subsumed under the terms protein energy wasting (PEW), which emphasized the protein loss in dialysis, and malnutrition-inflammation-atherosclerosis (MIA) syndrome, which highlighted chronic inflammation in dialysis patients; however, a variety of other factors contribute to weight loss, which are better described by the term chronic disease-related malnutrition (C-DRM). Weight loss is the most significant factor in recognizing malnutrition, as pre-existing obesity (especially type II diabetes mellitus) often makes the recognition more difficult. In the future, the increasing use of glucagon-like peptide 1 (GLP-1) agonists for weight loss could also lead to weight loss being perceived as intentional rather than distinguishing between intentional fat loss and unintentional loss of muscle mass.

Application of deep learning to predict the low serum albumin in new hemodialysis patients

BACKGROUND

Serum albumin level is a crucial nutritional indicator for patients on dialysis. Approximately one-third of patients on hemodialysis (HD) have protein malnutrition. Therefore, the serum albumin level of patients on HD is strongly correlated with mortality.

METHODS

In study, the data sets were obtained from the longitudinal electronic health records of the largest HD center in Taiwan from July 2011 to December 2015, included 1,567 new patients on HD who met the inclusion criteria. Multivariate logistic regression was performed to evaluate the association of clinical factors with low serum albumin, and the grasshopper optimization algorithm (GOA) was used for feature selection. The quantile g-computation method was used to calculate the weight ratio of each factor. Machine learning and deep learning (DL) methods were used to predict the low serum albumin. The area under the curve (AUC) and accuracy were calculated to determine the model performance.

RESULTS

Age, gender, hypertension, hemoglobin, iron, ferritin, sodium, potassium, calcium, creatinine, alkaline phosphatase, and triglyceride levels were significantly associated with low serum albumin. The AUC and accuracy of the GOA quantile g-computation weight model combined with the Bi-LSTM method were 98% and 95%, respectively.

CONCLUSION

The GOA method was able to rapidly identify the optimal combination of factors associated with serum albumin in patients on HD, and the quantile g-computation with DL methods could determine the most effective GOA quantile g-computation weight prediction model. The serum albumin status of patients on HD can be predicted by the proposed model and accordingly provide patients with better a prognostic care and treatment.

Restless leg syndrome in patients with chronic kidney disease: a hospital-based study from Upper Egypt

OBJECTIVES

Chronic kidney disease (CKD) is a common cause of restless leg syndrome (RLS). RLS is under-recognized, misdiagnosed and undertreated disorder in our locality. In this study, we aimed to determine the prevalence of RLS due to CKD and its predictors.

METHODS

This cross-sectional study included 520 patients [male = 200; female = 320; age: 48.45 ± 3.63yrs; uremia duration: 6.44 ± 1.65yrs; CKD5D = 400; CKD3D = 120). RLS diagnosis was done by clinical interviewing according to International RLS Study Group criteria. All underwent detailed biochemical testing and iron and ferritin levels' measurements. Insomnia, depression and anxiety severities were assessed using insomnia sleep index (ISI), Beck Depression Inventory (BDI-II) and State-Trait Anxiety Inventory for Adults (STAI-AD) scales.

RESULTS

RLS was found in 22.31% [ESKD = 26%, CKD3D = 10%]. Insomnia, depression and anxiety were found in 76.15%, 91.15% and 44.23%, respectively. Insomnia was correlated with depression (r = 0.488, p = 0.001) and anxiety (r = 0.360, p = 0.006) but not RLS. Multiple linear regression analysis showed that ESKD (OR = 3.8, 95%CI = 2.5-8.5, p = 0.001), inadequate dialysis (OR = 4.6, 95%CI = 3.5-8.6, p = 0.001), hyperparathyroidism (OR = 5.1, 95%CI 3.2-13.7, p = 0.0001) and peripheral neuropathy (OR = 5.6, 95%CI = 3.8-12.8, p = 0.0001) were independently associated with RLS.

CONCLUSION

The prevalence of RLS with CKD is 22.31%. It is 2.6 times more frequent and severe with ESKD compared to CKD3D. It seems that RLS may occur early with CKD and becomes worse with progressive kidney impairment. Also, insomnia, depression and anxiety are common with CKD, however, their severities were not correlated with RLS. Predictors for RLS were ESKD, inadequacy of dialysis, hyperparathyroidism and peripheral neuropathy.

Hemodiafiltration: Technical and Medical Insights

Despite the significant medical and technical improvements in the field of dialytic renal replacement modalities, morbidity and mortality are excessively high among patients with end-stage kidney disease, and most interventional studies yielded disappointing results. Hemodiafiltration, a dialysis method that was implemented in clinics many years ago and that combines the two main principles of hemodialysis and hemofiltration-diffusion and convection-has had a positive impact on mortality rates, especially when delivered in a high-volume mode as a surrogate for a high convective dose. The achievement of high substitution volumes during dialysis treatments does not only depend on patient characteristics but also on the dialyzer (membrane) and the adequately equipped hemodiafiltration machine. The present review article summarizes the technical aspects of online hemodiafiltration and discusses present and ongoing clinical studies with regards to hard clinical and patient-reported outcomes.

Sobrevida na hemodiálise no Brasil de acordo com a fonte pagadora do tratamento: Sistema Único de Saúde versus convênio privado

Resumo Introdução: O Brasil possui o maior sistema público e universal de saúde do mundo, mas pouco se sabe sobre os desfechos dos pacientes em hemodiálise (HD) no país de acordo com a fonte de financiamento do tratamento. Objetivo: Comparar o perfil e a sobrevida dos pacientes que têm o tratamento de HD custeado pelo Sistema Único de Saúde (SUS) com aqueles com convênio privado. Métodos: Análise retrospectiva dos adultos incidentes em HD entre 2012 e 2017 em 21 centros de diálise no Brasil que atendiam tanto pelo SUS quanto por convênios privados. Os participantes, independentemente da fonte pagadora, receberam tratamento dialítico semelhante. Os dados foram censurados com 60 meses de acompanhamento ou ao final de 2019. Resultados: Foram incluídos 4945 pacientes, sendo 59,7% financiados pelo SUS. Os pacientes financiados pelo SUS, em comparação aos que tinham convênio privado, eram mais jovens (58 vs 60 anos; p < 0,0001) e com menor prevalência de diabetes (35,8% vs 40,9%; p < 0,0001). As taxas de sobrevida, em 60 meses nesses grupos foram de 51,1% e 52,1%, respectivamente (p = 0,85). Na análise da razão de risco proporcional de subdistribuição pelo modelo de Fine-Gray, incluindo ajuste para desfechos concorrentes, foi encontrado um aumento significativo na razão de risco para morte (1,22 [intervalo de confiança de 95% 1,04 a 1,43]) nos pacientes com tratamento custeado pelo SUS. Conclusões: Pacientes em HD com tratamento custeado pelo SUS têm um risco ajustado de morte mais elevado do que aqueles com convênio privado, apesar do tratamento dialítico semelhante. Fatores não relacionados diretamente à terapia dialítica poderiam justificar esta diferença.

Associations of Air Pollution and Serum Biomarker Abnormalities in Individuals with Hemodialysis-Dependent Kidney Failure

BACKGROUND

Ambient particles with a median aerodynamic diameter of <2.5 µm (PM2.5) is a ubiquitous air pollutant with established adverse health consequences. While postulated to promote a systemic inflammatory response, limited studies have demonstrated changes in serum biomarkers related to PM2.5 exposure. We aim to examine associations between short-term PM2.5 exposure and commonly measured biomarkers known to be affected by inflammation among patients receiving maintenance in-center hemodialysis.

METHODS

We conducted a retrospective open cohort study from January 1, 2008, to December 31, 2014. Adult hemodialysis patients were identified from the United States Renal Data System and linked at the patient level to laboratory data from a large dialysis organization. Daily ambient PM2.5 was estimated on a 1-km grid and assigned to cohort patients based on the ZIP codes of dialysis clinics. Serum albumin, serum ferritin, transferrin saturation (TSAT), and serum hemoglobin were ascertained from the dialysis provider organization database. Mixed-effect models were used to assess the changes in biomarker levels associated with PM2.5 exposure.

RESULTS

The final cohort included 173,697 hemodialysis patients. Overall, the daily ZIP-level ambient PM2.5 averages were 8.4-8.5 µg/m3. A 10-µg/m3 increase in same-day ambient PM2.5 exposure was associated with higher relative risks of lower albumin (relative risk [RR], 1.01; 95% confidence interval [95% CI], 1.01 to 1.02) and lower hemoglobin (RR, 1.02; 95% CI, 1.01 to 1.03). Associations of same-day ambient PM2.5 exposure and higher ferritin and lower TSAT did not reach statistical significance.

CONCLUSIONS

Short-term PM2.5 exposure was associated with lower serum hemoglobin and albumin among patients receiving in-center hemodialysis. These findings lend support to the role of inflammation in PM2.5 exposure-outcome associations.

Anemia biomarkers and mortality in hemodialysis patients with or without diabetes: A 10-year follow-up study

BACKGROUND

Many studies have assessed the association between anemia and mortality in hemodialysis but few compared patients with and without diabetes. Our study aims to investigate the impact of hemoglobin and iron parameters on mortality in hemodialysis patients with or without diabetes.

METHODS

This is a two-center retrospective study that included all adult patients who started hemodialysis between February 2012 and February 2020, followed until January 2021. Averages of hemoglobin, ferritin and transferrin saturation of entire follow-up were recorded. Kaplan Meier survival, log rank test and cox regression analyses were performed to assess the association between anemia biomarkers and mortality.

RESULTS

A total of 214 patients were included. Mean age was 67.98 ±12.41 years, mean hemoglobin was 10.92 ±0.75 g/dL, mean ferritin was 504.43 ± 221.42 ng/mL and mean transferrin saturation was 26.23 ±7.77%. Log rank test showed an association between hemoglobin ≥11 g/dL and better survival in patients without diabetes (P = 0.028). Based on cox regression analysis, hemoglobin was associated with all-cause mortality in all patients (HR = 0.66; CI:0.49,0.89; P = 0.007). When comparing patients with and without diabetes, this association remained significant only in patients without diabetes (HR = 0.53; CI:0.37,0.77; P<0.001). Based on different multivariate models, hemoglobin, ferritin and age were independent factors associated with mortality in patients without diabetes.

CONCLUSIONS

This study showed that hemoglobin ≥11 g/dL is associated with better survival in hemodialysis patients without diabetes but not in those with diabetes. These differences need to be further explored in other countries and settings. An individualization of the hemoglobin target level might be necessary to improve patients' outcomes.

Influence of Modified Carbon Black on Nylon 6 Nonwoven Fabric and Performance as Adsorbent Material

The number of chronic kidney disease (CKD) persons continues to rise in Mexico. They require renal replacement therapy, and in the absence of it, hemodialysis is the major option for their survival. The uremic toxins present in the blood are removed by hemodialysis, which involve membranes. In this study, nonwoven fabrics with modified carbon black nanoparticles in a matrix polymer of Nylon 6 were obtained and evaluated as an adsorbent material of uremic toxins. All nonwoven fabrics were characterized by FTIR, XRD, TGA, SEM, and contact angle measurements and were evaluated as an adsorbent material for the urea toxin and as an albumin retainer. The findings suggest their potential application as a hemodialysis membrane. Nanocomposites had a higher hydrophilic characteristic compared to pure Nylon 6. The average diameter size of the fibers was in the range of 5 to 50 μm. All nanocomposites nonwoven fabrics showed high removal percentages of inulin in a range of 80-85% at 15 min of contact. Most Ny6 Zytel/CB nanocomposites showed a high percentage of urea removal (80 to 90%).

Synthesis and Anti-Tumor Effects of Novel Pomalidomide Derivatives Containing Urea Moieties

In order to explore novel immunomodulatory agents as anti-tumor drugs, we designed and synthesized a series of new pomalidomide derivatives containing urea moieties. Interestingly, in vitro biological experiments performed in several cancer cell lines showed that some of them displayed potent anti-tumor ability. These novel compounds 5a-5e and 6a-6e demonstrated the best cell growth inhibitive activity in human breast cancer cell lines MCF-7, but weaker inhibitive activity in human hepatocellular carcinoma cell lines Huh7. Moreover, compound 5d had the most powerful effects in this study, with an IC₅₀ value of 20.2 μM in MCF-7. Further study indicated that compound 5d could inhibit cell growth and induce cell death in a concentration-dependent manner. Besides, compound 5d increased cellular ROS levels and induced DNA damage, thereby potentially leading to cell apoptosis. These observations suggest that the novel pomalidomide derivatives containing urea moieties may be worth further investigation to generate potential anti-tumor drugs.

Discovery of Novel 1,2,3-triazole Derivatives as IDO1 Inhibitors

Indoleamine 2,3-dioxygenase 1 (IDO1) has received much attention as an immunomodulatory enzyme in the field of cancer immunotherapy. While several IDO1 inhibitors have entered clinical trials, there are currently no IDO1 inhibitor drugs on the market. To explore potential IDO1 inhibitors, we designed a series of compounds with urea and 1,2,3-triazole structures. Organic synthesis and IDO1 enzymatic activity experiments verified the molecular-level activities of the designed compounds, and the IC50 value of compound 3a was 0.75 μM. Molecular docking and quantum mechanical studies further explained the binding mode and reaction potential of compound 3a with IDO1. Our research has resulted in a series of novel IDO1 inhibitors, which is beneficial to the development of drugs targeting IDO1 in numerous cancer diseases.

Delivery of Radioiodine Ablation in a Patient with End-Stage Renal Disease

This case presents a pragmatic approach to the management of a radioiodine remnant ablation patient on hemodialysis which required no pretherapeutic dosimetric measurements. Pretreatment radiation dose modeling was performed using literature values for radioiodine hemodialysis extraction efficacies to determine a safe treatment regimen including adjustment of the administered activity and hemodialysis frequency. The pretreatment modeling was subsequently verified using external and blood radiation monitoring during treatment.

The association between dose of hemodialysis and patients mortality in a prospective cohort study

Dialysis adequacy is a known risk factor for mortality in maintenance hemodialysis (MHD) patients. However, the optimal dialysis dose remains controversial. Therefore, we aimed to explore the relationship between dialysis dose and all-cause and cardiovascular disease (CVD) mortality among MHD. We examined the associations of dialysis dose with mortality in a cohort (n = 558) of MHD patients from 31 December 2015 to 31 December 2020. Dialysis adequacy was assessed using baseline Single-pool Kt/Vurea (spKt/V), which was categorized into three groups, and the lowest dose group was used as the reference category. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression models. A total of 214 patients died (64.5% for CVD). Compared with the low-dose group, high-dose group could reduce the risk of all-cause mortality by 33% (HR = 0.67, 95% CI: 0.47-0.98). Of note, when stratification by age, high-dose group was associated with both lower all-cause (HR = 0.46, 95% CI: 0.26-0.81) and CVD mortality (HR = 0.42, 95% CI: 0.20-0.88) among patients with age below 65 years. When stratification by dialysis age, high-dose group was associated with decreased risk of CVD mortality (HR = 0.43, 95% CI: 0.20-0.91) among patients with dialysis age over 60 months. spKt/V is a simple index of hemodialysis dose used in clinical practice and a useful modifiable factor in predicting the risk of death, especially in MHD patients under 65 years old or dialysis age more than 60 months.

Low serum albumin: A neglected predictor in patients with cardiovascular disease

Albumin, the most abundant circulating protein in blood, is an essential protein which binds and transports various drugs and substances, maintains the oncotic pressure of blood and influences the physiological function of the circulatory system. Albumin also has anti-inflammatory, antioxidant, and antithrombotic properties. Evidence supports albumin's role as a strong predictor of cardiovascular (CV) risk in several patient groups. Its protective role extends to those with coronary artery disease, heart failure, hypertension, atrial fibrillation, peripheral artery disease or ischemic stroke, as well as those undergoing revascularization procedures or with aortic stenosis undergoing transcatheter aortic valve replacement, and patients with congenital heart disease and/or endocarditis. Hypoalbuminemia is a strong prognosticator of increased all-cause and CV mortality according to several cohort studies and meta-analyses in hospitalized and non-hospitalized patients with or without comorbidities. Normalization of albumin levels before discharge lowers mortality risk, compared with hypoalbuminemia before discharge. Modified forms of albumin, such as ischemia modified albumin, also has prognostic value in patients with coronary or peripheral artery disease. When albumin is combined with other risk factors, such as uric acid or C-reactive protein, the prognostic value is enhanced. Although albumin supplementation may be a plausible approach, its efficacy has not been established and in patients with hypoalbuminemia, priority is focused on diagnosing and managing the underlying condition. The CV effects of hypoalbuminemia and relevant issues are considered in this review. Large cohort studies and meta-analyses are tabulated and the physiologic effects of albumin and the deleterious effects of low albumin are pictorially illustrated.

Contribution of Hypoalbuminemia and Anemia to the Prognostic Value of Plasma p-Cresyl Sulfate and p-Cresyl Glucuronide for Cardiovascular Outcome in Chronic Kidney Disease

Free plasma concentrations of protein-bound uremic toxins (PBUTs) may be influenced by serum albumin and hemoglobin. The potential association of serum albumin and hemoglobin with free levels of p-cresyl sulfate (pCS) and p-cresyl glucuronide (pCG) and their predictive value for cardiovascular morbidity and mortality were explored. A total of 523 non-dialysis chronic kidney disease (CKD) stages G1–G5 patients were prospectively followed for the occurrence of fatal or non-fatal cardiovascular events over a 5.5-year period. A negative correlation was found between albumin and between hemoglobin, and both total and free pCS and pCG. In multiple linear regression, PBUTs were negatively associated with eGFR (estimated glomerular filtration rate) and hemoglobin but not albumin. In multivariate Cox regression analysis, albumin was a predictor of outcome, independent of pCS and pCG, without interactions between albumin and pCS or pCG. The relation of low hemoglobin with adverse outcome was lost when albumin was entered into the model. Lower concentrations of pCS and pCG are associated with higher serum albumin and hemoglobin. This may indicate that there are two pathways in the blood that potentially contribute to attenuating the vasculotoxic effects of these PBUTs. The association of PBUTs with cardiovascular risk is not explained by albumin levels, which remains a strong and independent predictor for adverse outcome.

Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment

The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists' support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient's condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There are also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).

Plasma C4 level was associated with mortality, cardiovascular and cerebrovascular complications in hemodialysis patients

BACKGROUND

Patients on maintenance hemodialysis (HD) exhibit a high risk of death, cardiovascular and cerebrovascular diseases (CCDs). Previous studies indicated complement activation associated with the increased risk of cardiovascular diseases in HD patients. This study aimed to explore whether the critical complement factors were associated with the adverse outcomes in HD patients.

METHODS

A total of 108 HD patients were included and followed up for 52 months. The baseline clinical characteristics and plasma C3c, C1q, CFH, CFB, C4, MAC, C5a, C3a and MBL were measured. The three endpoints were death, cardiovascular and cerebrovascular events (CCEs) and the composition of them. Univariate and multivariate Cox regression identified factors associated with the three endpoints respectively. X-tile analyses determined the optimal cut-off values for high risks. Restricted cubic spline plots illustrated the dose-response relationships. Correlations between the complement factors and risk factors for CCDs were analyzed.

RESULTS

Baseline plasma C4 was finally selected by univariate and multivariate Cox regression analyses for three endpoints, including all-cause mortality, CCEs and the composition of them. When baseline plasma C4 exceeded 0.47 (P = 0.001) or 0.44 (P = 0.018) g/L respectively, the risks for death or achieving the composite endpoint enhanced significantly. The relationships of C4 and HR for the three endpoints showed a positive linear trend. Plasma C4 had prominent correlations with blood TG (r = 0.62, P < 0.001) and HDL (r = -0.38, P < 0.001).

CONCLUSIONS

A higher baseline plasma C4 level was significantly associated with the future incidence of decease, CCEs and either of them. Plasma C4 level correlated with blood TG and HDL.

Predialysis Urea Nitrogen Is a Nutritional Marker of Hemodialysis Patients

End-stage renal disease (ESRD) patients on hemodialysis have poor nutritional status and associated problems such as inflammation and sarcopenia. Blood urea nitrogen (BUN) is an important measure of uremic toxins, and urea reduction is a marker of hemodialysis efficacy. However, a low protein diet for lower BUN could aggravate malnutrition in patients, and optimal pre-dialysis BUN is not defined. We investigated the association of pre-dialysis BUN with patients' comorbidities and the relationship between pre-dialysis BUN and serum albumin as a nutrient marker. Among the 67 patients, the average pre- and post-dialysis BUN were 59.2 and 15.0 mg/dL, respectively, serum creatinine was 10.1 mg/dL, and the average serum albumin was 4.0 g/dL. Patients' age was negatively correlated with serum creatinine (r=-0.277, p<0.05) and albumin (r=-0.453, p<0.001). Predialysis BUN showed a significant positive correlation with serum albumin (r=0.287, p<0.05) and creatinine (r=0.454, p<0.001). However, the predialysis BUN was not significantly related to diabetes, coronary artery disease, congestive heart failure, or cerebrovascular disease. Hemodialysis patients with high pre-dialysis BUN and high serum creatinine could be regarded as having good nutritional status. The significance of this study lies in the potential utility of pre-dialysis blood urea nitrogen as an indicator of the nutritional status of patients. Liberal protein intake might be recommended to adequately dialyzed patients.

Efficacy of a Communication-Priming Intervention on Documented Goals-of-Care Discussions in Hospitalized Patients With Serious Illness: A Randomized Clinical Trial

IMPORTANCE

High-quality goals-of-care communication is critical to delivering goal-concordant, patient-centered care to hospitalized patients with chronic life-limiting illness. However, implementation and documentation of goals-of-care discussions remain important shortcomings in many health systems.

OBJECTIVE

To evaluate the efficacy, feasibility, and acceptability of a patient-facing and clinician-facing communication-priming intervention to promote goals-of-care communication for patients hospitalized with serious illness.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial enrolled patients from November 6, 2018, to February 18, 2020. The setting was 2 hospitals in an academic health care system in Seattle, Washington. Participants included hospitalized adults with chronic life-limiting illness, aged 65 years or older and with markers of frailty, or aged 80 years or older. Data analysis was performed from August 2020 to August 2021.

INTERVENTION

Patients were randomized to usual care with baseline questionnaires (control) vs the Jumpstart communication-priming intervention. Patients or surrogates in the intervention group and their clinicians received patient-specific Jumpstart Guides populated with data from questionnaires and the electronic health records (EHRs) that were designed to prompt and guide a goals-of-care discussion.

MAIN OUTCOMES AND MEASURES

The primary outcome was EHR documentation of a goals-of-care discussion between randomization and hospital discharge. Additional outcomes included patient-reported or surrogate-reported goals-of-care discussions, patient-reported or surrogate-reported quality of communication, and intervention feasibility and acceptability.

RESULTS

Of 428 eligible patients, this study enrolled 150 patients (35% enrollment rate; mean [SD] age, 59.2 [13.6] years; 66 women [44%]; 132 [88%] by patient consent and 18 [12%] by surrogate consent). Seventy-five patients each were randomized to the intervention and control groups. Compared with the control group, the cumulative incidence of EHR-documented goals-of-care discussions between randomization and hospital discharge was higher in the intervention group (16 of 75 patients [21%] vs 6 of 75 patients [8%]; risk difference, 13% [95% CI, 2%-24%]; risk ratio, 2.67 [95% CI, 1.10-6.44]; P = .04). Patient-reported or surrogate-reported goals-of-care discussions did not differ significantly between groups (30 of 66 patients [45%] vs 36 of 66 patients [55%]), although the intrarater consistency of patient and surrogate reports was poor. Patient-rated or surrogate-rated quality of communication did not differ significantly between groups. The intervention was feasible and acceptable to patients, surrogates, and clinicians.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, a patient-facing and clinician-facing communication priming intervention for seriously ill, hospitalized patients promoted EHR-documented goals-of-care discussions before discharge with good feasibility and acceptability. Communication-priming interventions should be reexamined in a larger randomized clinical trial to better understand their effectiveness in the inpatient setting.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03746392.

Advance Identification of Patients With Chronic Conditions and Acute Respiratory Failure at Greatest Risk for High-Intensity, Costly Care

CONTEXT

Patients with underlying chronic illness requiring mechanical ventilation for acute respiratory failure are at risk for poor outcomes and high costs.

OBJECTIVES

Identify characteristics at time of intensive care unit (ICU) admission that identify patients at highest risk for high-intensity, costly care.

METHODS

Retrospective cohort study using electronic health and financial records (2011-2017) for patients requiring ≥48 hours of mechanical ventilation with ≥1 underlying chronic condition at an academic healthcare system. Main outcome was total cost of index hospitalization. Exposures of interest included number and type of chronic conditions. We used finite mixture models to identify the highest-cost group.

RESULTS

4,892 patients met study criteria. Median cost for index hospitalization was $135,238 (range, $9,748 -$3,176,065). Finite mixture modelling identified three classes with mean costs of $89,980, $150,603, and $277,712. Patients more likely to be in the high-cost class were: 1) < 72 years old (OR: 2.03; 95% CI:1.63, 2.52); 2) with dementia (OR: 1.55; 95% CI:1.17, 2.06) or chronic renal failure (OR: 1.27; 95% CI:1.08, 1.48); 3) weight loss ≥ 5% in year prior to hospital admission (OR: 1.25; 95% CI:1.05, 1.48); and 4) hospitalized during prior year (OR: 1.92; 95% CI:1.58, 2.35).

CONCLUSION

Among patients with underlying chronic illness and acute respiratory failure, we identified characteristics associated with the highest costs of care. Identifying these patients may be of interest to healthcare systems and hospitals and serve as one indication to invest resources in palliative and supportive care programs that ensure this care is consistent with patients' goals.

International consensus statement on allergy and rhinology: Olfaction

BACKGROUND

The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O).

METHODS

Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus.

RESULTS

The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies.

CONCLUSION

This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

Impact of kidney size on the outcome of diabetic patients receiving hemodialysis

INTRODUCTION

Diabetic patients normally have enlarged or normal-sized kidneys throughout their lifetime, but some diabetic uremic patients have small kidneys. It is uncertain if kidney size could have any negative impact on outcome in hemodialysis patients.

METHODS

This longitudinal, observational cohort study recruited 301 diabetic hemodialysis patients in 2015, and followed until 2019. Patients were stratified into two subgroups according to their kidney sizes before dialysis, as small (n = 32) or enlarged or normal (n = 269). Baseline demographic, hematological, biochemical, nutritional, inflammatory and dialysis related data were collected for analysis.

RESULTS

Patients with small kidney size were not only older (P<0.001) and had lower body mass index (P = 0.016), but had also higher blood uric acid concentration (P<0.001) compared with patients with enlarged or normal kidney size. All patients received adequate doses of hemodialysis since the Kt/V and urea reduction ratio was 1.7±0.3 and 0.7±0.1, respectively. Patients with small size kidneys received higher erythropoietin dose than patients with enlarged or normal kidney size (P = 0.031). At the end of analysis, 92 (30.6%) patients expired. Kaplan-Meier analysis revealed no survival difference between both groups (P = 0.753). In a multivariate logistic regression model, it was demonstrated that age (P<0.001), dialysis duration (P<0.001), as well as blood albumin (P = 0.012) and low-density lipoprotein (P = 0.009) concentrations were significantly correlated with mortality.

CONCLUSIONS

Small kidney size on starting hemodialysis was not related with an augmented risk for death in diabetic patients receiving hemodialysis. Further studies are necessary.

Identifying the Association of Time-Averaged Serum Albumin Levels with Clinical Factors among Patients on Hemodialysis Using Whale Optimization Algorithm

Time-averaged serum albumin (TSA) is commonly associated with clinical outcomes in hemodialysis (HD) patients and considered as a surrogate indicator of nutritional status. The whale optimization algorithm-based feature selection (WOFS) model could address the complex association between the clinical factors, and could further combine with regression models for application. The present study aimed to demonstrate an optimal multifactor TSA-associated model, in order to interpret the complex association between TSA and clinical factors among HD patients. A total of 829 HD patients who met the inclusion criteria were selected for analysis. Monthly serum albumin data tracked from January 2009 to December 2013 were converted into TSA categories based on a critical value of 3.5 g/dL. Multivariate logistic regression was used to analyze the association between TSA categories and multiple clinical factors using three types of feature selection models, namely the fully adjusted, stepwise, and WOFS models. Five features, albumin, age, creatinine, potassium, and HD adequacy index (Kt/V level), were selected from fifteen clinical factors by the WOFS model, which is the minimum number of selected features required in multivariate regression models for optimal multifactor model construction. The WOFS model yielded the lowest Akaike information criterion (AIC) value, which indicated that the WOFS model could achieve superior performance in the multifactor analysis of TSA for HD patients. In conclusion, the application of the optimal multifactor TSA-associated model could facilitate nutritional status monitoring in HD patients.

Update on Pediatric Hemodialysis Adequacy

The use of high reflux dialyzers to achieve a Kt/V_urea above 1.2 did not improve patient survival in most literature reports. After an electronic search in many sites, guidelines, systematic reviews, and review articles (cited references): We recommend (1) using the equilibrated double-pool, weekly rather than per session, Kt/V_urea, (2) Use of UF-dry weight to avoid V changes, (3) consider protein catabolic Rate (4) Use of double pool to avoid urea generation rebound effect. Beyond the urea model, other recommended parameters include the middle molecule clearance and patient clinical data as blood pressure control, normal ventricular morphology, and function, absence of anemia, bone mineral disease, vascular calcifications, good nutrition and growth, long-lasting vascular access, less intra-dialysis hypotension, fewer hospitalizations related to complications as infection, long-term patient survival with better life quality. All mentioned parameters are the good markers for adequate dialysis. Since (1) frequent short and (or) slow long dialysis sessions show better solute clearance and hemodynamic stability associated with better control of cardiovascular and bone disease, anemia, nutrition, and growth with better quality of life and survival. (2) The spare in the cost of the antihypertensive medications, erythroid-stimulating drugs, phosphate binders, and frequent hospitalization, compensates for the high dialysis cost. (3) The use of some advisable techniques can minimize access trauma; therefore, HD Model can be changeable according to each patient's clinical and biochemical follow-up dialysis adequacy progress pattern.

A pilot study comparing the efficiency of a novel asymmetric cellulose triacetate (ATA) dialyser membrane (Solacea-190H) to a standard high flux polysulfone dialyser membrane (FX-80) in the setting of extended hours haemodialysis

Aim

To compare small, middle and large‐middle molecule clearance; and expression of markers of inflammation, between Solacea‐190H (asymmetric cellulose triacetate [ATA]) and FX‐80 dialysers in long‐hour haemodialysis patients.

Methods

This pilot, randomized cross‐over trial recruited 10 home haemodialysis patients. The total study duration was 8 weeks, using each dialyser for 4 weeks. Removal of small (urea, phosphate, creatinine and indoxyl sulfate [IS]), middle and large‐middle molecules (beta‐2 microglobulin [β2M], albumin), markers of inflammation (interleukin‐6 [IL‐6], malondialdehyde‐modified low density lipoprotein [MDA‐LDL] and alpha‐1 microglobulin [α1M]), was evaluated in serum and dialysate samples.

Results

Reduction ratios [RR] were calculated for variables at the fourth week of each dialyzer sequence and results expressed as difference in mean RR between dialyzers. There was no difference in clearance of small molecules, with difference in mean RR for urea −2.43 (95% CI ‐6.44, 1.57; p = .19), creatinine −1.82 (95% CI ‐5.50, 1.85; p = .28) and phosphate −2.61 (95% CI −12.45, 7.23; p = .55); clearance of middle and large‐middle molecules with difference in mean RR (range) for β2M 2.2 (95% CI −3.2, 7.7; p = .35), IS 1.8 (95% CI −9.5, 13; p = .72) and albumin −0.6 (95% CI −5.5, 4.2; p = .77). There was lack of induction of markers of inflammation, including IL‐6 15.2 (95% CI −31.9, 62.2; p = .47), MDA‐LDL −8.1 (95% CI ‐22.1, 5.8; p = .21) and α1M −3.50 (95% CI −29.2, 22.2; p = .76). Dialysate removal results were concurrent.

Conclusion

This study showed no difference in clearance of small, middle and large‐middle molecules, nor expression of markers of inflammation between dialysers.

This pilot cross‐over randomized controlled trial compares small, middle and large‐middle molecule clearance between Solacea‐190H (asymmetric cellulose triacetate [ATA]) and FX‐80 dialysers in 10 patients using long‐hour haemodialysis over an 8‐week period, and showed no difference in clearance between the two dialysers.

Characteristics and predictors of mortality on haemodialysis in Brazil: a cohort of 5,081 incident patients

Background

Although Brazil has one of the largest populations on haemodialysis (HD) in the world, data regarding patients’ characteristics and the variables associated with risk of death are scanty.

Methods

This is a retrospective analysis of all adult patients who initiated on maintenance HD at 23 dialysis centres in Brazil between 2012 and 2017. Patients were censored after 60 months of follow-up or at the end of 2019.

Results

A total of 5,081 patients were included in the analysis. The median age was 59 years, 59.4% were men, 37.5% had diabetes as the cause of kidney failure. Almost 70% had a central venous catheter (CVC) as the initial vascular access, about 60% started dialysis in the hospital, and fluid overload (FO) by bioimpedance assessment was seen in 45% of patients. The 60-month survival rate was 51.4%. In the Cox regression analysis, being older (P<0.0001), starting dialysis in the hospital (P=0.016), having diabetes as the cause of kidney failure (P=0.001), high alkaline phosphatase (P=0.005), CVC as first vascular access (P=0.023), and FO (P<0.0001) were associated with higher death risk, whereas higher body mass index (P=0.015), haemoglobin (P=0.004), transferrin saturation (P=0.002), and serum albumin (P<0.0001) were associated with better survival. The same variables, except initial CVC use (P=0.14), were associated with death risk in an analysis of subdistribution proportional hazards ratio including the competing outcomes.

Conclusions

The present study gives an overview of a large HD population in a developing country and identifies the main predictors of mortality, including some potentially modifiable ones, such as unplanned initiation of dialysis in the hospital and fluid overload.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02705-x.

Serum Hypoalbuminemia Is a Long-Term Prognostic Marker in Medical Hospitalized Patients, Irrespective of the Underlying Disease

Hypoalbuminemia is common in hypoalbuminemia-associated disorders (HAD), e.g., liver and kidney disease. We hypothesize that hospitalized patients with hypoalbuminemia have poor prognosis irrespective of their underlying disease. Records of patients admitted to Medicine (2010−2018), with and without HAD were analyzed, comparing low (<35 g/L) to normal serum albumin. Mann−Whitney and Chi-squared tests were used, and a logistic regression model was applied. Patients: 14,640 were admitted; 9759 were analyzed (2278 hypoalbuminemia: 736 HAD, 1542 non-HAD). All patients, and the subgroups with (as expected) and without HAD had worse outcomes. Specifically, in patients without HAD, those with hypoalbuminemia (n = 1542) vs. normal albumin (n = 6216) were older, had a higher Charlson Comorbidity Index (CCI, 5 vs. 4), longer median hospital stay (5 vs. 4), higher one year re-admission rate (49.9% vs. 39.8%), and one year mortality (48.9% vs. 15.3%, p < 0.001 for all). LR model predicting 3 month, 1 year and 5 year mortality confirmed the predictive power of albumin (1 year: OR = 4.49 for hypoalbuminema, p < 0.01). Hypoalbuminemia portends poor long-term prognosis in hospitalized patients regardless of the underlying disease and could be added to prognostic predictive models.